Spine (Phila Pa 1976). 2011 Jun 15;36(14):1146-53.
Posterior multilevel vertebral osteotomy for severe and rigid idiopathic and nonidiopathic kyphoscoliosis: a further experience with minimum two-year follow-up.
Modi HN, Suh SW, Hong JY, Yang JH.
Source

Department of Orthopedics, Scoliosis Research Institute, Korea University Guro Hospital, Seoul, South Korea.
Abstract
STUDY DESIGN:

Prospective randomized study.
OBJECTIVE:

To evaluate the clinica! and radiologic outcome of posterior multilevel vertebral osteotomy (PMVO) in patients with severe kyphoscoliosis.
SUMMARY OF BACKGROUND DATA:

Authors have developed and reported results of PMVO for correction of neuromuscular scoliosis. PMVO has advantages such as, posterior-only procedure which avoids risk to pulmonary complications and gives satisfactory correction. However, its effect in correcting severe scoliosis in presence of rigid kyphosis has not been reported.
METHODS:

Thirteen patients (7 idiopathic, 4 cerebral palsy, and 2 congenital scoliosis) with severe and rigid kyphoscoliosis were operated by posterior-only correction with pedicle screw fixation using PMVO. As per pathology, and associated severity of kyphosis little modification in the original technique was applied while correction and osteotomy. Neuromonitoring was applied in all patients during operation. The radiologic and clinical results were evaluated with an average follow-up of 42.9±11 months. All postoperative complications were also noted during the follow-up period.
RESULTS:

Average number of osteotomy was 4.2±0.8 (range, 3-5). Average preoperative Cobb angle, pelvic obliquity, thoracic kyphosis, and lumbar lordosis were 99.2°±29.6°, 8.6°±9°, 73.6°±56.9°, and -47.2°±63.2°, respectively, which improved after surgery to 44.7°±12.3°, 2.8°±2.9°, 45.3°±15.9°, and -47.7°±12.2°. All corrections were maintained at final follow-up. A 54.3% correction was achieved in coronal plane; and, full correction was achieved in sagital plane as thoracic kyphosis was restored within normal range. Average blood loss and operative time was 3015±1213 mL and 6.01±1.09 hours, respectively. Three patients had postoperative respiratory complications; 2 had hemothorax and 1 had atelectasis; none had follow-up consequences. All pulmonary complications were due to associated thoracoplasty during which pleura was ruptured intraoperatively. Two patients had complication related with the implants; 1 screw breakage and other screw prominence. There was no neurologic injury intraoperatively on motor-evoked po- tentials (MEP) or clinically after surgery.
CONCLUSION:

PMVO exhibited satisfactory clinical and radiologic results in patients with severe and rigid scoliosis associated with hyperkyphosis at minimum 2-year follow-up. It can be safely applied with modifications in original technique for complex congenital scoliosis with multilevel hemi or block vertebrae and idiopathic/nonidiopathic spinal deformities.

Eur Spine J. 2011 Jul;20(7):1087-94. Epub 2011 Jan 28.
Idiopathic scoliosis in Korean schoolchildren: a prospective screening study of over 1 million children.
Suh SW, Modi HN, Yang JH, Hong JY.
Source

Scoliosis Research Institute, Department of Orthopedics, Korea University Guro Hospital, 80 Guro-Dong, Guro-Gu, Seoul, South Korea.
Abstract

Cross-sectional epidemiologic scoliosis screening was carried out to determine the current prevalence of scoliosis in the Korean population and to compare with the results of previous studies. Between 2000 and 2008, 1,134,890 schoolchildren underwent scoliosis screening. The children were divided into two age groups, 10-12-year-olds (elementary school) and 13-14-year-olds (middle school), to calculate age- and sex-specific prevalence rates. Children with a scoliometer reading ≥5° were referred for radiograms. Two surgeons independently measured curve types, magnitudes, and Risser scores (inter-observer r = 0.964, intra-observer r = 0.978). Yearly and overall prevalence rates of scoliosis were calculated. There were 584,554 boys and 550,336 girls in the sample, with a male to female ratio of 1.1:1. There were 77,910 (6.2%) children (26,824 boys and 51,086 girls) with scoliometer readings >5°, and 37,339 of them had positive results with Cobb angles ≥10° (positive predictive value, 46.4%). The overall scoliosis prevalence rate was 3.26%; girls had a higher prevalence (4.65%) than boys (1.97%). Prevalence rates increased progressively from 1.66 to 6.17% between 2000 and 2008, with the exception of 2002. According to age and gender, 10-12-year-old girls had the highest scoliosis prevalence rates (5.57%), followed by 13-14-year-old girls (3.90%), 10-12-year-old boys (2.37%), and 13-14-year-old boys (1.42%). In girls and boys, prevalence rates dropped by 64.53 and 60.65% among 10-12-year-olds and 13-14-year-olds, respectively (P = 0.00). The proportion of 10°-19° curves was 95.25 and 84.45% in boys and girls, respectively; and the proportion of 20°-29° curves was 3.91 and 11.28%, which was a significant difference (P = 0.00). Thoracic curves were the most common (47.59%) followed by thoracolumbar/lumbar (40.10%), double (9.09%), and double thoracic (3.22%) curves. A comparison of the curve patterns revealed significant differences between genders (P = 0.00). We present this report as a guide for studying the prevalence of idiopathic scoliosis in a large population, and the increasing trend in the prevalence of idiopathic scoliosis emphasizes the need for awareness.

INTRODUCTION

Stem cell research is advancing knowledge about how an organism develops from a single cell and how healthy cells replace damaged cells in adult organisms. This promising area of science is also leading scientists to investigate the possibility of cell-based therapies to treat disease, which is often referred to as regenerative or reparative medicine.


WHAT ARE STEM CELLS?

Stem cells are cells found in most multi-cellular organisms. They have two important characteristics that distinguish them from other types of cells. First, they are unspecialized cells that renew themselves for long periods through mitotic cell division and differentiation. The second is that under certain physiologic or experimental conditions, they can be induced to become cells with special functions such as the beating cells of the heart muscle or the insulin-producing cells of the pancreas.

The two broad types of mammalian stem cells are: embryonic stem cells that are isolated from the inner cell mass of blastocysts, and adult stem cells that are found in adult tissues.

Stem cells are important for living organisms for many reasons. In the 3- to 5-day-old embryo, called a blastocyst, stem cells in developing tissues give rise to the multiple specialized cell types that make up the heart, lung, skin, and other tissues. In some adult tissues, such as bone marrow, muscle, and brain, discrete populations of adult stem cells and progenitor cells act as repair system for the body, replenishing specialized cells, but also maintaining the normal turnover of regenerative organs, such as blood, skin, or intestinal tissues.
Stem cells can now be grown and transformed into specialized cells with characteristics consistent with cells of various tissues such as muscles or nerves through cell culture.
Highly plastic adult stem cells from a variety of sources, including umbilical cord blood and bone marrow, are routinely used in medical therapies. Embryonic cell lines and autologous embryonic stem cells generated through therapeutic cloning have also been proposed as promising candidates for future therapies.[3




UNIQUE PROPERTIES OF STEM CELLS
Stem cells differ from other kinds of cells in the body and regardless of their origin have three general properties. They are capable of dividing and renewing themselves for long periods; they are unspecialized; and can give rise to specialized cell types.
Stem cells do not have any tissue-specific structures that allow it to perform specialized functions. A stem cell cannot work with its neighbours to pump blood through the body (like a heart muscle cell); it cannot carry molecules of oxygen through the bloodstream (like a red blood cell), nor can it fire electrochemical signals to other cells that allow the body to move or speak (like a nerve cell), but, more importantly, it can give rise to the development of these specialized cells by a process known as differentiation.
The internal signals are controlled by a cell's genes, which are interspersed across long strands of DNA, and carry coded instructions for all the structures and functions of a cell. The external signals for cell differentiation include chemicals secreted by other cells, physical contact with neighbouring cells, and certain molecules in the microenvironment.
Unlike the above mentioned specialized cells, stem cells are capable of proliferating for long periods. A starting population of stem cells that proliferates for many months in the laboratory can yield millions of cells. If the resulting cells continue to be unspecialized, like the parent stem cells, the cells are said to be capable of long-term self-renewal.
Adult stem cells typically generate the cell types of the tissue in which they reside. A blood-forming adult stem cell in the bone marrow, for example, normally gives rise to the many types of blood cells such as red blood cells, white blood cells and platelets. Until recently, it had been thought that a haematopoietic stem cell in the bone marrow could not give rise to the cells of a very different tissue, such as nerve cells in the brain. However, a number of experiments over the last several years have raised the possibility that stem cells from one tissue may be able to give rise to cell types of a completely different tissue, a phenomenon known as plasticity. Examples of such plasticity include blood cells becoming neurons, liver cells that can be made to produce insulin and haematopoietic stem cells that can develop into heart muscle.









HISTORY OF STEM CELL RESEARCH
• 1908 - The term "stem cell" was proposed for scientific use by the Russian histologist Alexander Maksimov (1874–1928) at congress of hematologic society in Berlin. It postulated existence of haematopoietic stem cells.
• 1960s - Joseph Altman and Gopal Das present scientific evidence of adult neurogenesis, ongoing stem cell activity in the brain; like André Gernez, their reports contradict Cajal's "no new neurons" dogma and are largely ignored.
• 1963 - McCulloch and Till illustrate the presence of self-renewing cells in mouse bone marrow.
• 1968 - Bone marrow transplant between two siblings successfully treats SCID.
• 1978 - Haematopoietic stem cells are discovered in human cord blood.
• 1981 - Mouse embryonic stem cells are derived from the inner cell mass by scientists Martin Evans, Matthew Kaufman, and Gail R. Martin. Gail Martin is attributed for coining the term "Embryonic Stem Cell".
• 1992 - Neural stem cells are cultured in vitro as neurospheres.
• 1997 - Leukemia is shown to originate from a haematopoietic stem cell, the first direct evidence for cancer stem cells.
• 1998 - James Thomson and coworkers derive the first human embryonic stem cell line at the University of Wisconsin–Madison.[60]
• 2000s - Several reports of adult stem cell plasticity are published.
• 2001 - Scientists at Advanced Cell Technology clone first early (four- to six-cell stage) human embryos for the purpose of generating embryonic stem cells.[61]
• 2003 - Dr. Songtao Shi of NIH discovers new source of adult stem cells in children's primary teeth.[62]
• 2004–2005 - Korean researcher Hwang Woo-Suk claims to have created several human embryonic stem cell lines from unfertilised human oocytes. The lines were later shown to be fabricated.
• 2005 - Researchers at Kingston University in England claim to have discovered a third category of stem cell, dubbed cord-blood-derived embryonic-like stem cells (CBEs), derived from umbilical cord blood. The group claims these cells are able to differentiate into more types of tissue than adult stem cells.
• 2005 - Researchers at UC Irvine's Reeve-Irvine Research Center are able to partially restore the ability of mice with paralyzed spines to walk through the injection of human neural stem cells.
• August 2006 - Rat Induced pluripotent stem cells: the journal Cell publishes Kazutoshi Takahashi and Shinya Yamanaka.[63]

• October 2006 - Scientists at Newcastle University in England create the first ever artificial liver cells using umbilical cord blood stem cells.[64][65]
• January 2007 - Scientists at Wake Forest University led by Dr. Anthony Atala and Harvard University report discovery of a new type of stem cell in amniotic fluid.[66] This may potentially provide an alternative to embryonic stem cells for use in research and therapy.[67]
• June 2007 - Research reported by three different groups shows that normal skin cells can be reprogrammed to an embryonic state in mice.[68] In the same month, scientist Shoukhrat Mitalipov reports the first successful creation of a primate stem cell line through somatic cell nuclear transfer[69]
• October 2007 - Mario Capecchi, Martin Evans, and Oliver Smithies win the 2007 Nobel Prize for Physiology or Medicine for their work on embryonic stem cells from mice using gene targeting strategies producing genetically engineered mice (known as knockout mice) for gene research.[70]
• November 2007 - Human induced pluripotent stem cells: Two similar papers released by their respective journals prior to formal publication: in Cell by Kazutoshi Takahashi and Shinya Yamanaka, "Induction of pluripotent stem cells from adult human fibroblasts by defined factors",[71] and in Science by Junying Yu, et al., from the research group of James Thomson, "Induced pluripotent stem cell lines derived from human somatic cells":[72] pluripotent stem cells generated from mature human fibroblasts. It is possible now to produce a stem cell from almost any other human cell instead of using embryos as needed previously, albeit the risk of tumorigenesis due to c-myc and retroviral gene transfer remains to be determined.
• January 2008 - Robert Lanza and colleagues at Advanced Cell Technology and UCSF create the first human embryonic stem cells without destruction of the embryo[73]
• January 2008 - Development of human cloned blastocysts following somatic cell nuclear transfer with adult fibroblasts[74]
• February 2008 - Generation of pluripotent stem cells from adult mouse liver and stomach: these iPS cells seem to be more similar to embryonic stem cells than the previous developed iPS cells and not tumorigenic, moreover genes that are required for iPS cells do not need to be inserted into specific sites, which encourages the development of non-viral reprogramming techniques.[75]
• March 2008-The first published study of successful cartilage regeneration in the human knee using autologous adult mesenchymal stem cells is published by clinicians from Regenerative Sciences[76]
• October 2008 - Sabine Conrad and colleagues at Tübingen, Germany generate pluripotent stem cells from spermatogonial cells of adult human testis by culturing the cells in vitro under leukemia inhibitory factor (LIF) supplementation.[77]
• 30 October 2008 - Embryonic-like stem cells from a single human hair.[78]
• 1 March 2009 - Andras Nagy, Keisuke Kaji, et al. discover a way to produce embryonic-like stem cells from normal adult cells by using a novel "wrapping" procedure to deliver specific genes to adult cells to reprogram them into stem cells without the risks of using a virus to make the change.[79][80][81] The use of electroporation is said to allow for the temporary insertion of genes into the cell.[82][83][84][85]
• 28 May 2009 Kim et al. announced that they had devised a way to manipulate skin cells to create patient specific "induced pluripotent stem cells" (iPS), claiming it to be the 'ultimate stem cell solution'.[86]
DEVELOPMENT OF STEM CELL RESEARCH

The spinal cord needs more protection then any other organ or system because unlike other organs, the spinal cord once damaged, cannot regenerate. While the majority of cells found in the central nervous system are born during the embryonic and early postnatal period, scientists recently discovered that new neurons are continuously added to two specific regions of the adult mammalian brain (Reynolds and Weiss 1992). Neural stem cells were isolated from the dentate gyrus of the hippocampus and the walls of the ventricular system called the ependymal layer. The progeny of these stem cells differentiate in the granule cell layer, meaning neurogenesis continues late into adult rodent life. These stem cells also migrate along the rostral migratory stream to the olfactory bulb, where they differentiate into neurons and glial cells (Luskin, 1993). Nerve cell differentiation has been witnessed in vivo, as well as in vitro when stimulated with an epidermal growth factor (Gage, 1995).
Along with pluripotent stem cells progenitor cells, a more restricted type of stem cells, are found in the hippocampus and ependymal layer. These cells are immature cells that are predetermined to differentiate into neurons, oligodendrocytes, and astrocytes. In 1995 Frissen observed that the presence of nestin increases in response to spinal cord injury. Nestin is a protein expressed by stem cells: presence of it indicates neural stem cells are much more active then previously believed. Our brain naturally increases the production of stem cells to aid an injured CNS. In 1999, Johansson and Momma observed that the only active progenitor cells were differentiating into astrocytes. They labeled ependymal cells with a Dil injection so migration could be followed. After making lesions in the spinal cord they waited four weeks and then observed the progress of the ependymal cells. They tested the cells found in the scar tissue around the site of injury and found that all DIL marked cells were astrocytes. This indicates that the progeny from ependymal cells had only differentiated to astrocytes. Stem cells do respond to spinal cord injury, just not for the purpose of reestablishing connection between neurons.
This realization sparked scientist’s interest in understanding what triggers these progenitor cells to proliferate. Scientists began to focus on neurotrophic factors that triggered this differentiation, specifically the presence of brain derived neurotrophic factors (BDNF) and neurotrophin 3 and 4 (NT-3 and NT-4). In the early 90’s these trophic factors were targeted as what triggered axon growth during early development. NT-3 also is expressed in greater amounts in response to spinal cord injury. In 1994 Schwab reported dramatic increase in function, and regrowth of a partially severed cord of rats after treatment with NT-3. In 1997 Grill, Gage, and colleagues published a paper examining the effects of transplanted NT-3 on motor skills and morphology after induced spinal injury in mice. They focused on the corticospinal tract, the pathway in charge of making voluntary movements. NT-3 has been previously observed to promote regrowth of corticospinal axons, and preserves degenerating motor neurons.
Grill and colleagues induced lesions in the dorsal hemisection of adult rat’s spinal cord, resulting in severely limited motor ability. Next grafts of syngenic fibroblasts, genetically altered to produce NT-3, were transplanted into the lesion cavity of the experimental group. These rats were kept alive for three months and put though a series of tests to monitor motor improvement. These tests examined coordination, ability to walk on inclined surfaces and precision of foot placement. After three months these rats were killed for the purpose of a quantitative cell count.
Recipients of the NT-3 secreting grafts showed significant improvement in motor skills over the control group, although they did not recover to the full ability they had before injury. After three months recipients of the NT-3 grafts demonstrated growth of corticospinal axons up to 8 mm from where the stem cells were transplanted. Only the injured axons at the lesion site showed any sign of regrowth. Uninjured axons showed no effort to reestablish connections across the site of injury. This suggests that NT-3 only responds when corticospinal axons are injured. If scientists could pinpoint signals triggering this response there is potential to manipulate the process in a manner causing neural cells to differentiate.
Triggering neurotrophic factors in hopes of inducing progenitors to proliferate is one of two major areas of study in spinal cord regeneration. Scientists also can derive undifferentiated embryonic stem cells (ES cells) from foetal spinal cord tissue and then mature them into cells that are suitable to implant into the damaged spinal cord. When using ES cells, researchers have two options: they can treat ES cells, allowing them to mature into CNS cells in vitro before transplantation, or they can directly implant differentiated cells and depend on signals from the brain mature the cells. This technique became possible when Reynolds and Weiss found that stem cells taken from the brain could be propagated in vitro. This allowed labs to duplicate what occurs naturally in the brain, and attempt to use the product to re-grow the damaged cells.
In December of 1999 McDonald and colleagues from Washington University School of medicine successfully implanted ES cells in laboratory rats. McDonald induced thoracic spinal cord injury in rats using a metal rod 2.5 mm in diameter resulting in paralysis. Nine days after the injury McDonald and colleagues transplanted roughly 1 million ES embryoid bodies pre-treated with retinoic acid into the syrinx that had formed around the contusion. During the nine days that passed between injury and transplantation, all the standard events following a spinal cord injury occurred. At the time of injury some cells died immediately, followed by a second wave of apoptosis within the first 24 hours. The centre of the bruised spine filled with fluid becoming a cyst referred to as syrinx. McDonald injected the ES cells into this cavity.
Two weeks after the transplantation ES stem cells filled the area normally occupied by glial scarring. After five weeks the stem cells had migrated further away from the implantation site. Although a number of them had died, there was still enough for the rats to have a growing supply of neurons and glial cells. Most of the surviving cells were oligodendrocytes and astrocytes, but some neurons were found in the middle of the cord. The rats regained limited use of their legs. Paralysis had been cured!!
McDonalds work in 1999 represented new successes in stem cell technology but this technology is yet to be tested in humans. A major obstacle remains: although scientists are achieving results, they don’t understand the factors responsible for what occurs. In McDonalds study, the regaining of functions could result from the few differentiated neurons. Another possibility could be that the high differentiation of oligodendrocytes re-myelinated enough axons to reestablish communication. Or perhaps functions regained due to ES cells producing growth factors—more research will have to be done before these options are narrowed down. Additional to unclear understanding of the process, other complications exist. Any introduction of foreign cells into the body triggers the immune system. ES cells would not simply be accepted into the host CNS. McDonald used cyclosporine to prevent rejection in the rats, but things get more complicated when testing begins on humans. The brain and spinal cord is complex, mysterious realms of the body—until science can predict the exact affect of evolving technologies, no testing on humans can occur.
A major motivation behind spinal cord research has been Christopher Reeve. Injured in a horseback riding incident, Christopher Reeve suffered a cervical spinal cord injury that left him quadriplegic. Christopher Reeve began the Christopher Reeve Paralysis Foundation (CRPF). CPRF funds research to treat or cure paralysis resulting from spinal cord injury or other CNS disorders. CPRF supports a Research Consortium, which collaborates the work of nine laboratories, as well as funds an international individual grants program. Several of the labs involved in the Research consortium focus on stem cells, making a lot of progress. The Salk Institute, run by Dr. Fred Gage examines the progenitor cells differentiating into glial cells. Someday they hope to manipulate these progenitor cells, inducing differentiation into neural cells.
STEM CELL TRANSPLANT VS ETHICS
There are a lot of people who find stem cell research extremely unethical. Scientists have found the most success with ES cells taken from embryoid spinal cords: although the ES cells are taken from embryos consisting at most of 64 cells, they still have potential to develop into a human being. People who believe life begins at conception remain morally against stem cell research. Justification is that the stem cells are derived from embryos discarded from fertility clinics. These embryos would be wasted if not used for stem cell research. Christopher Reeve published a position paper in response to the moral concerns and President Bush's decisions on stem cell researching. CPRF supports responsible stem cell research, recognizing the fine ethical boundaries existing in this technology.
TRANSPLANTATION OF STEM CELLS INTO SPINAL CORD
The original cell transplantation technology has been developed in the Centre for treating SCI patients. After surgically disrupting an intramedullary cyst (see Figure 1), the spinal cord defect is entirely filled up with the special gel containing foetal-derived, immature stem cells (see Figure 2). Moreover, during several months after the surgery each patient is subarachnoidally grafted with foetal-derived cells one or more times. The donor cell combination that is highly effective in generating regenerative processes in an adult nervous tissue has been previously determined by special experimental studies.

Figure 1. Dissection of the connective tissue cyst and opening access to the cord defect.

Figure 2. Infill of the spinal cord defect with the cell- containing gel implant.

FUTURE OF STEM CELLS

It has been hypothesized by scientists that stem cells may, at some point in the future, become the basis for treating diseases such as Parkinson's disease, diabetes, and heart disease.
As scientists learn more about stem cells, it may become possible to use the cells not just in cell-based therapies, but also for screening new drugs and toxins and understanding birth defects.
N.B.: This article was an e learning exercise by medical student Ms Kausalyaa Krishnabalan of Melaka Manipal Medical College , Malaysia

PAIN MANAGEMENT :
NEW SUPERSPECIALITY::- DR.NEERAJ JAIN M.D.
9810033800 (M)

“It is easier to find a man who will volunteer to die, than to find those who are willing to endure pain with patience” Julius Caesar

Remember:-“No one dies of pain but many die in pain and many more live with pain” “Freedom from pain is human right”

Pain is 5th vital sign as per W.H.O. Pain is now understood as primary medical condition. “The neurosignature of pain experience is determined by the synaptic architecture of the neuromatrix”

Pain Medicine, a super-specialty, deals with the management of these difficult chronic painful disease states including treatment of cancer pain. A majority of complex chronic painful states, unresponsive to conventional treatment are being successfully treated at Pain Clinics. The very concept of a Pain Clinic is based on the conviction that the effective management of difficult pain conditions is possible only through well-coordinated efforts of a specialist possessing knowledge and skills to diagnose and treat pain.

A Pain Clinic uses services of specialties such as neurology, psychology, physical therapy, orthopedics, anaesthesiology and neurosurgery. “Comprehensive multidisciplinary pain management centre” is the highest pain management facility/ centre of excellence, which is equivalent to super specialty cardiac / neuro / nephrology centre.

Thus, Pain Clinics are specialized areas that are now assuming the role of an essential service as they meet a need unmet by any previously existing medical facility. They help by simultaneously treating the physical, emotional, cognitive, behavioral, vocational and social aspects of chronic pain cost-effectively.

Chronic pain is a disease, a syndrome not just a symptom.
Chronic pain can lead to depression, anxiety, marital & interpersonal problems, decreased productivity, unemployment, compromised social roles, isolation, financial burden, dependence, prolonged analgesics usage, decreased self esteem with behavioral changes adversely affecting quality of life (QOL) & activities of daily living (ADL).
“The pain of mind is worse than the pain of body”
“Chronic pain is something you wear on inside, not on the outside”
“Not tonight, dear. I have a backache.” Backache is second only to headaches as the most common location of pain.
Pain is one of the most common reasons for patients to seek medical attention and one of the most prevalent medical complaints in today’s world.
Some 75 million Americans experience persistent pain and at least nine per cent of the USA adult population is estimated to suffer from moderate to severe non-malignant pain. Patients with chronic (or “persistent”) pain can be especially difficult to treat. In one survey conducted for the American pain society, 47 per cent of those with moderate, severe or very severe pain had challenged physicians at least once since their initial visit for pain relief. When asked why, they cited continued suffering (42 per cent), the physician’s lack of knowledge (31 per cent), not taking the pain seriously enough (29 per cent), and unwillingness to treat it aggressively (27 per cent) as reasons for the change. Situation in India is not very different from this one.
Despite these startling statistics pain still remains inappropriate & inadequately treated. Although tremendous scientific & technological advances have been made, the knowledge & techniques are highly underutilized. This is due to lack of dissemination of information to clinicians. “It’s easy to be paranoid when you hurt like hell and you are on the mercy of healthcare system”.
The clinicians must learn to make distinction between acute and chronic pain before embarking upon treatment. The skill of proper pain management lies in not in ability to perform difficult advanced blocks but in the determination of appropriate diagnosis & therapeutic modalities

The treatment of the acute, chronic & cancer pain is demanding & challenging. Effective pain management presents a significant challenge for physicians, other healthcare professionals, and their patients.
A problem arises when chronic pain feels like acute pain, is described to (and is accepted by) physicians and therapists as acute pain, and is then treated as acute pain. When this happens results are apt to be disappointing to both the patient and the physician and both may end up feeling quite frustrated. To both recover from, and to treat, chronic pain requires taking a different approach.
“Take two aspirins & go to bed” dictum of old days is over “What can’t be cured has to be endured” has changed with the role of the interventional pain specialist. Pain speciality It’s a “medical necessity”
There have been many advances in the understanding & usefulness of an intervention at right time in selective patients producing excellent results.

Our ultimate goal is to cure & care people suffering from pain, make them productive human beings for the society and increase their self esteem so that they can live life as normal individuals.
Interventional pain procedures scores over both medicine and surgery, as they do not have side effects like medicines. Surgeries for pain, have now limited indications, usually as a last resort.
The interventional pain procedures produce immediate pain relief, can be performed with ease by pain physicians without anesthesia as outpatient or daycare and adequate duration of pain relief obtained and suitable for surgically unfit & debilitated patients, procedure can be repeated safely if required.
In the absence of proper education among health care professionals and lack of awareness in the public mind in India, there is misuse of painkillers resulting in high incidence of complications like gastritis, kidney failure, and bone marrow depression.
The Indian health care scene has a curious mix of paradoxes. Advances in cardiovascular surgery or high-tech investigative facilities in India are on par with any advanced country, at least in some cities. Though skills, advanced equipments are available, still pain relief is not available to majority of its population. At least a million people in India suffer unrelieved cancer pain. The number of people suffering other chronic pain conditions is anyone’s guess. Paradoxically, India stands high chance to become the health destination for pain management for the world, by using interventional pain therapies and very effective traditional therapies unique to India.
With the advancement of technology and science, we have unveiled many aspects of the pain and its treatment. We have to work hard to spread the knowledge of interventional pain techniques. Our goal is to help people suffering from pain, make them productive human being for the society and increase their self esteem so that they can live life as normal individuals.
Unfortunately awareness about pain management among medical professionals is very limited. In contrast to USA and other developed countries Indian medical community is not aware of interventional pain management techniques which can be helpful for many patients suffering from intractable chronic pain.
Pain treatment is tailor-made & no single treatment fits all.
Under treatment of pain is a major public health concern. It is a silent epidemic, don’t let this happen to someone you love. Untreated pain destroys people’s lives. I have had patients come in who couldn’t work or sleep or play with their children. Good pain management gave them their lives back. It is cruel to deny people in pain access to effective pain treatment. People should not be suffering needlessly.
“Pain is real & treatable - There is no merit in suffering!”
----------------------------------------------
“Control pain before it controls you” as “Pain begets pain”
“Sweet is death that takes away pain” is true for cancer pain.
“Pain is more terrible master than death itself”
“For all the happiness man can gain, is not in pleasure but freedom from pain”.
“Pain has the thousand teeth”.
“You purchase pain with faulty lifestyle” “All pain is a punishment”



CONTROL PAIN BEFORE IT CONTROLS YOU !
FOR ADVANCED PAIN MANAGEMENT OF:-

CHRONIC INTRACTABLE PAIN SYNDROMES
BACK PAIN / LEG PAIN (DISCOGENIC/SPINAL CANAL STENOSIS)
FACET JOINT SYNDROME/SPINAL ARTHRITIS
SPINE (AXIAL) PAIN (CERVICAL/LUMBOSACRAL/THORACIC)
SACROILITIS / STRAIN & COCCYDYNIA
DISC DISEASES (HERNIA/PROLAPSE/RUPTURE/SLIPPED)
REDICULOPATHY / SCIATICA
NEURALGIC PAINS / PLEXOPATHIES
HERPES ZOSTER PAIN /NEURALGIA (PHN)
TRIGEMINAL / CRANIAL NEURALGIAS
SPASTIC CEREBRAL/SPINAL PALSY
REFLEX SYMPATHETIC DYSTROPHIES (RSD)
COMPLEX REGIONAL PAIN SYNDROMES (CRPS 1 & 2)
FAILED BACK SURGERY SYNDROMES (FBSS)
MUSCULOSKELETAL / MYOFASCIAL PAIN SYNDROMES
VASOSPASTIC ISCHEMIC PAINS
NEUROGENIC CLAUDICATION
CERVICOGENIC / TENSION/CLUSTER HEADACHES
POST SURGICAL / POST TRAUMATIC / SPORTS INJURY PAINS
CENTRAL PAIN STATES
FIBROMYALGIA
CANCER PAIN/ END OF LIFE PAIN / AIDS PAINS
CHRONIC VISCERAL / PELVIC PAIN SYNDROMES
FRACTURE SPINE (COMPRESSION # OF VERTEBRA)
OSTEOPOROSIS / METASTATIC / PAGET`S DISEASE BONE PAINS
HYPERHIDROSIS (WET HANDS/UNDERARMS/FEET)

REMEMBER: NO ONE DIES OF PAIN BUT MANY DIE IN PAIN
AND EVEN MORE LIVE WITH PAIN !

“HELP THEM”

NON SURGICAL TECHNIQUES OF SPECIALISED
FLUOROSCOPIC/ULTRASOUND/NERVE STIMULATOR/CT GUIDED
PERCUTANEOUS INTERVENTIONAL PROCEDURES
FOR DIAGNOSTIC/THERAPEUTIC/NEUROLYSIS OF:-

DIAGNOSTIC EPIDUROGRAPHY FOLLOWED BY
TRANSFORAMINAL / INTERLAMMINAR EPIDURAL MEDICATION AT
CERVICAL / THORACIC / LUMBAR / SACRAL / CAUDAL LEVELS
SELECTIVE NERVE ROOT SHEATH BLOCK (SNRB)
PROVOCATIVE DISCOGRAPHY & INTRADISCAL INTERVENTIONS
LUMBAR/CERVICOTHORACIC SYMPATHETIC BLOCKS / NEUROLYSIS
PERCUTANEOUS VERTEBROPLASTY (PVP)
FACET JOINT/ SACROILIAC JOINT / PIRIFORMIS BLOCKS
DECOMPRESSIVE NEUROPLASTY / EPIDURAL ADENOLYSIS
INTRATHECAL OPIATE/BACLOFEN PUMP IMPLANTS
SPINAL CORD STIMULATOR/NEUROMODULATION IMPLANTS
CRANIAL NERVES BLOCKS / NEUROABLATIONS
TRIGEMINAL GANGLIOLYSIS
SOMATIC NERVE / MYOFASCIAL / MYONEURAL BLOCKS
TRIGGER POINT INJECTIONS WITH STEROIDS/BOTOX/NEUROLYTICS
STELLATE/CELIAC PLEXUS/HYPOGASTRIC/IMPAR NEUROLYSIS
BOTOX CHEMODENERVATION
PROLOTHERAPY/MESOTHERAPY/INTRAMUSCULAR STIMULATION
INTERPLEURAL CATHETER /SPLANCHNIC BLOCKS
PARAVERTEBRAL / PSOAS COMPARTMENT BLOCKS
NERVE SHEATH & PLEXUS CATHETERISATION & MEDICATION
LASER LESSIONING / RADIOFREQUENCY (RF) NEUROABLATIONS
CONTACT:-
DR. NEERAJ JAIN M.D.
SENIOR CONSULTANT INTERVENTIONAL PAIN SPECIALIST
SPINE & PAIN CLINIC
98100 33800 (M) 27341685 (C)
,
SRI BALAJI ACTION MEDICAL INSTITUTE

Without question, some of the most dynamic acupuncture points on the human body are known as the Hua Tuo Jia Ji points. These points, philosophically and clinically, may effectively treat every condition of the human system. My teachers - Master Kiiko Matsumoto and David Euler start back treatments using Huato Jiaji points.

They are extremely easy to locate and use. They respond not only to the acupuncture needle but through any type of percussion such as a neurological reflex hammer, Wartenberg pin wheel, tuning fork, green and red laser, percussive instrument, gua sha, tei shein (noninvasive needle) or firm digital pressure. Any form of stimulation works absolute wonders in clinical practice.

These classic points are located just half a cun, or human inch (the distance across the widest part of the patient's thumb) bilateral to Du Mai (GV) (midline over the vertebral spinous process) from T1 through L5. Classically there are 17 pairs of points (34 points total) attributed to Hua Tuo. Within the last 2,000 years, these points have extended both upward through the cervical spine and downward across the sacrum. The points in the cervical and sacrum are simply known as jia (lining) ji (spine).

The points were discovered by the legendary physician Hua Tuo, who was born in 110 A.D. and lived to the almost unprecedented age of 97. He was reputedly murdered by the ruler of the Wei Dynasty after he suspected an assassination attempt when Hua Tuo suggested brain surgery for his severe headaches. Hua Tuo was rumored to have found the secrets of exceptional health and longevity.

Only the 17 bilateral points attributed to Hua Tuo carry his name as Hua Tuo Jia Ji. These points are located at the level of the spinous process of the vertebrae 0.5 cun from the midline. The shu (associated points) of the 12 primary meridians beginning at T3 are located 1.5 cun from the Du Mai midline. These points work startlingly similar to the meric system of chiropractic. Chiropractic's explanation of its exceptional clinical response in most health conditions is that of an insulted nerve at the level of the intervertebral foramina due to displacement of the vertebrae (a vertebral fixation). These spinal fixations will cause both hypertonicity and hypotonicity of the paravertebral musculature, resulting in neurothlipsis or so-called "pinched nerve." The involved nerve will affect the organ and tissue. It is well known in chiropractic that the third thoracic vertebrae has a direct response on anything in the level of the lung to include the bronchi, pleura, chest, breast, etc. This same explanation extends up and down the spine to affect all organs, muscles, bones and structures of the body.

Hua Tuo, on the other hand, developed a system of healing which appears to be remarkably similar to chiropractic but 2,000 years prior to the discovery of both osteopathy and chiropractic. By the stimulation of these specific points at the precise vertebral level, virtually any condition can be positively affected. That does not mean to say these points will cure everything, however the success rate in using these points at the precise locations is nothing short of miraculous. The key is understanding the exact level of the vertebra in relation to the organ and tissue it controls. For example, Thoracic 6 is specific to the Stomach, whereas Thoracic 7 and 8 are specific to the Spleen/Pancreas. The jia ji points of C7 is specific to the thyroid, as well as the shoulders and elbows.

The classic acupuncture point known as BL10 is 1.3 cun bilateral to DU15, which is just below the pseudo spinous of the first cervical vertebrae. However the jia ji point, located 0.5 cun lateral to DU15, will affect the pituitary gland, scalp, brain, inner and middle ear, and sympathetic nervous system. An "energetic subluxation" at this point will manifest itself in neurasthenia, insomnia, hypertension, migraine, chronic tiredness, vertigo, headaches and susceptibility to colds.

These reflexes are very specific and have been a vital part of certain specialty practices of chiropractic for well over a century. The stimulation of the Hua Tuo Jia Ji points are not routine or well known in the chiropractic profession. However, the reflex levels are classic and extremely well established. Chiropractic physicians will routinely adjust the vertebrae by hand or cause hyperstimulation through automatic or manual adjusting devices.

I always advise practitioners to stimulate not only the Hua Tuo Jia Ji point but the GV and, if appropriate, the shu point during treatment. Gua sha is an exceptional way to stimulate these points as it is quick, easy and effective.

In as much as the specific reflex areas of the spine are generally only used by specialty chiropractic practices, it is assumed that most acupuncture practitioners are unaware of these specific locations. Electro-meridian imaging (EMI) will direct the practitioner to the precise vertebral level since any meridian involvement will always reflex directly to the spine. This is an exceptional way to determine general levels to be treated. However, if one knows the specific areas affected, it is a matter of academia to select the proper level or combination of levels. Contact me directly with your request for a specific meric reflex chart and begin using this absolutely incredible system of acupuncture. You will be amazed at the response.